CID-07455; No of Pages 4

Clinics in Dermatology (xxxx) xx, xxx

Clio Dermatologica
Edited by Mauricio Goihman-Yahr, MD, PhD

Cupping on ancient Greek coins: A numismatic

case series and its relationship to dermatology
Rosalind Ashton, MD, MSc a,⁎, Irina Nocivin, MD, MSc b , Richard HJ Ashton, MA, FSA c ,
Nicholas Levell, MD, FRCP, MBA d
a
Department of Family Medicine, University of Ottawa School of Medicine, Ottawa, Ontario, Canada
b
Foundation Doctor, Royal Surrey County Hospital, Egertin Rd, Guildford, United Kingdom SE1 7EH
c
Editor (Ancient) of The Numismatic Chronicle, c/o Department of Coins and Medals, British Museum, London, UK WC1B 3DG
d
Consultant Dermatologist & Research Lead: Norfolk & Norwich University Hospital, Norfolk, UK

Abstract Cupping is an ancient medical therapy with a modern-day resurgence. This practice has been
referred to in the ancient Egyptian papyri and the writings of Hippocrates and Galen. We attempt to bridge
the past with the present by showcasing a series of ancient Greek coins from different mints depicting
medical cupping vessels and dating as far back as the 4th century BCE. This practice has not been suffi-
ciently studied in randomized controlled trials, and a standardized procedure does not exist. The derma-
tologist may see the consequences of this practice in the office, as it is a complementary medical technique
supposed to treat a variety of ailments from joint pain to menstrual problems and leaves a very character-
istic morphology. We have showcased three coins of historic numismatic and medical interest that depict
ancient cupping vessels. This is the first time these coins have been presented together. A literature search
was also performed to outline the theories of the mechanism of action of cupping and to compile a list of
reported dermatologic side effects.
© 2020 Elsevier Inc. All rights reserved.

Background any beneficial effects. Different cultures employing this

technique have put forth theories regarding the mechanism
Cupping is an ancient complementary medicine technique of cupping that combine philosophic and/or religious tenets
used and valued by many cultures worldwide, although its with a variable knowledge of physiology and anatomy.
origins remain unclear. The first written source to mention According to the Chinese medical tradition, disease is caused
the use of cupping appears in the Egyptian papyrus, Ebers, by disruption or congestion of qi, the circulating life force,
ca 1550 BCE. The practice is also mentioned in the writings whose flow can be restored by the use of cupping applied
of Hippocrates (c.460-377 BCE) and Galen (c.131-200 CE).1 over important acupuncture points.2 This is similar to
There remains uncertainty, despite much speculation, the Hippocratic humor theory of disease, refined by Galen,
about the exact process by which cupping might exert who posited that build-up of blood, phlegm, yellow bile,
and black bile contributed to the development of disease.
Encouraging and facilitating the expulsion of these harmful
⁎ Corresponding author. Tel.: +1 613 797 8804. humors through phlebotomy or cupping help to restore
E-mail address: [email protected] (R. Ashton). balance and treat the ailment.

https://doi.org/10.1016/j.clindermatol.2020.05.002
0738-081X/© 2020 Elsevier Inc. All rights reserved.
2 R. Ashton et al.

Fig. 1 Epidauros. Bronze, 4.54 g, 17 mm, ca 225-200 BCE. Obverse Laureate head of Asklepios right Reverse Epione (wife of Asklepios)
advancing left, feeding goose from phiale; to right, cupping vessel; to left, monogram of ΕΠ. Handbook of Greek Coins 5: 173, no. 731. Clas-
sical Numismatic Group Inc. E-auction 179 (2008), lot 71.

Case series lost, but the occurrence of the cupping vessel, often with a
subsidiary symbol of a pair of forceps or a scalpel, on all
We present three examples from ancient Greek numismatics, the rare autonomous coin issues of the city is sufficient to
where cupping vessels are illustrated (the English word show that medicine and the cult of Asklepios were estab-
“numismatics” ultimately is derived from the Greek lished practices there.
nomisma, meaning inter alia a “coin”; the “nummular” in We present three striking examples (Figures 1 to 3),
“nummular dermatitis” derives from its Latin cognate nummus). one from each of these mints, all with a cupping vessel on
the reverse (tails side), two with a head of Asklepios on the
obverse (heads side) and the third with an unidentified head
of a woman.
Discussion Cupping is an element of alternative medicine used in
many cultures. Its origin dates to traditional Chinese,
Cupping vessels are known to have been used as the main Greek, and Egyptian practices. The ancient vessels employed
types or subsidiary symbols on the silver and bronze in this practice were probably made of metal, as archeologic
coinages of several ancient Greek cities between the mid- evidence found in Greece would suggest. The three coins
4th and early 2nd centuries BCE: most notably Epidauros in presented probably depict bronze vessels, though this is not
the Peloponnese, Astakos on the coast of Akarnania in conclusive. Other materials used may have included shell
west-central Greece, and Aigiale on the island of Amorgos and animal horn.4
near Naxos.⁎ Epidauros was the most famous of Asklepios’
sanctuaries and a renowned center of healing. No direct evi-
dence of an Asklepian cult or healing center has yet been
found at the two other cities, but the dominance of Asklepios, How to perform cupping
his symbols on the coinage of Aigiale, and indirect evidence
from the rest of the island led Liampi to write: The modern technique of cupping involves the application
From this information it may be concluded that medical
of glass vessels that contain ignited alcohol-soaked cotton.
science was practiced systematically on the island, and There are two types of cupping:
it is obvious that it was protected by the physician-god,
whom they did not hesitate to represent on the coins of 1. Dry cupping: simple application of the cupping vessel on
Aigiale with the cupping-vessel.3 the skin
2. Wet cupping: an incision may be performed before appli-
For Astakos, the only other physical evidence for a cation to promote expulsion of blood
sanctuary of Asklepios was a relief depicting Asklepios
and his daughter Hygieia, found at nearby Alyzeia but now Upon cooling, the cup generates a partial vacuum creating
an area of congestion and hyperemia. This process is thought
⁎ to be beneficial by eliminating toxins or lessening stasis.
Respectively, HGC 5: 173-175 Nos. 731, 733, 742; HGC 4: 234 Nos.
801-805; HGC 6: 186-187, Nos. 759-761, 763-764. In the past, the bronzes Bruises formed over the treated areas are considered the mark
of Astakos were erroneously given to Atrax in Thessaly.2 of a successful treatment. Another modification of traditional
Cupping in ancient numismatics and dermatology 3

Fig. 2 Astakos, Akarnania. Bronze, 2.60 g, 13 mm, ca 360-330 BCE. Obverse Female head right Reverse Cupping vessel; to right, forceps; to
left ASTA2 257, group III Nos. 6 to 7 variant; Handbook of Greek Coins 4: 234, No. 805 variant. Pecunem (Naumann) auction (September 7,
2014), lot 154.

cupping is the use of lubrication, when engaged cups are There are several theories on how the practice allegedly
moved over the skin, leaving behind linear ecchymotic works. Some believe that the negative pressure created
streaks.5 The mechanism for what may be considered benefi- increases circulation, alleviates pain, and helps to eliminate
cial remains unclear. toxic substances deposited in the tissue. Another possibility
is the counter-irritation theory, according to which the
disease is transferred to another site in the body. Lastly, the
Uses proposed effects of cupping may be solely psychosomatic.9
Patients and their families, who are dissatisfied with
In the Far East, cupping has been used for treating a Western medicine and its failure to produce rapid results,
variety of ailments, ranging from sacral pain, discomfort of may simultaneously turn to traditional therapies without con-
the shoulders or legs, menstrual problems, indigestion, and sidering the potential pitfalls. Some patients opt for comple-
even asthma.6 Additional uses throughout the world include mentary or “natural remedies” in the belief that they are
applications for fibromyalgia, arthralgia, headache, cough, risk-free. Adverse events from therapies such as cupping
joint pain, and a variety of inflammatory skin complaints.7 should be regularly reported to build a database for use in
The most common sites for applying the cup are the back, counseling future patients. In addition, there is the recogni-
arms, abdomen, and buttocks. The procedure usually takes tion of the lack of randomized controlled trials conclusively
from 5 to 20 minutes.8 proving its efficacy.

Fig. 3 Aigiale, Amorgos. Bronze, 4.65 g, 17 mm. ca 200-180 BCE. Obverse Laureate head of Asklepios right Reverse Cupping vessel; to left,
snake.3 100, Nos. 20 to 21; Handbook of Greek Coins 6: 186, No. 759. Münzen und Medaillen Deutschland GmbH auction 21 (2007), lot 497;
Münzen und Medaillen AG, Basel, auction 76 (1991), lot 712.
4 R. Ashton et al.

The practice of cupping is not without side effects. The most 4. Mehta P, Dhapte V. Cupping therapy: a prudent remedy for a plethora of
obvious would be the deliberate provocation of ecchymosis medical ailments. J Tradit Complement Med 2015;5:127-134.
5. Yoo SS, Tausk F. Cupping: East meets West. Int J Dermatol 2004;43:
through shearing forces that injure the papillary dermal capillaries, 664-665.
leaving the characteristic nummular hyperpigmentation. Addi- 6. Lilly E, Kundu RV. Dermatoses secondary to Asian cultural practices.
tionally, there may be Koebner phenomena,8,9 scarring,10,11 pan- Int J Dermatol 2012;51:372-382.
niculitis formation,12 postinflammatory hyperpigmentation,13,14 7. Turk JL, Allen E. Bleeding and cupping. Ann R Coll Surg Engl
1983;65:128-131.
Herpes simplex infections,15 bullous formation,16 and accidental
8. Vender R, Vender R. Paradoxical, cupping-induced localized psoriasis:
burns.17,18 Unfortunately, cupping might even be confused with a Koebner phenomenon. J Cutan Med Surg 2015;19:320-322.
child abuse.19 9. Balighi K, Daneshpazhooh M, Azizpour A, et al. Koebner phenomenon
in pemphigus vulgaris patients. JAAD Case Rep 2016;2:419-421.
10. Birol A, Erkek E, Kurtipek GS, et al. Keloid secondary to therapeutic
cupping: an unusual complication. JEADV 2005;19:503-523.
Conclusions 11. Franco G, Calcaterra R, Valenzano M. Cupping-related skin lesions.
Skinmed 2012;10:315-318.
12. Lee JS, Ahn SK, Lee SH. Factitial panniculitis induced by cupping and
Aside from the historic interest, it is fascinating to note acupuncture. Cutis 1995;55:217-218.
that this medical practice has survived for many centuries 13. Kim KHK, Kim TT-H, Hwangbo M, et al. Anaemia and skin pigmenta-
with little to no alteration to its technique. Its popularity has tion after excessive cupping therapy by an unqualified therapist in Korea:
endured and migrated into Western culture (illustrated by a case report. Acupunct Med 2012;30:227-228.
reported use among Olympic athletes such as swimmer 14. Mataix J, Belinchon I, Banuls J, et al. Skin lesions from the application
of suction cups for therapeutic purposes. Actas Dermosifiliogr 2006;97:
Michael Phelps and Hollywood celebrities). 20 Physician 212-214.
knowledge of its existence and adverse effects are important 15. Jung YJ, Kim JH, Lee HJ, et al. A herpes simplex virus infection
in order to effectively counsel patients about cupping. secondary to acupuncture and cupping. Ann Dermatol 2011;23:67-69.
16. Win CW, Wang JTJ, Choy CS, et al. Iatrogenic bullae following
cupping therapy. J Alt Complement Ther 2009;15:1243-1245.
17. Iblher N, Stark B. Cupping treatment and associated burns risk: a plastic
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